The human and economic cost of hard-to-heal wounds. Richard Searle Health Economics Manager Smith & Nephew Wound Management Division

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1 The human and economic cost of hard-to-heal wounds Richard Searle Health Economics Manager Smith & Nephew Wound Management Division

2 Outline 1. The economics of wound care: cost, resources and value as fundamental concepts 2. The impact of wounds on health care resources All wounds Non-healing wounds 3. Non-healing wounds: strategies for reducing resource use

3 The economics of wound care: cost, resources and value as fundamental concepts

4 Economic cost Economic cost is really about the use of resources HCP time (e.g. nurse and surgeon time) Dressings and other materials Hospital costs Lost productivity Economic cost of wounds is not just about the price of wound care products It s the opportunity cost Economic cost can be reduced by reducing any or all of the resources required to heal a wound, and not just by releasing cash

5 Measuring cost Perspective A given provider Healthcare system Public sector The patient Society Costs which might be included Healthcare resources: variable and fixed Patient expenses, patient resources Resources in other sectors Measure resources used Costs Multiply by unit costs

6 General shape of cost distribution Frequency Cost per what? For example Cost per week / month / year Cost per episode Cost

7 Most of the cost of wound care is hidden The relatively low proportion of dressing cost does not mean dressings are unimportant The choice of dressing can have a vital impact on the other resources used Dressings and materials Typically 10% - 15% of total cost Clinician time Hospitalisation Typically 25% -30% of total cost Typically 50%+ of total cost

8 Cost per case vs cost per week Time

9 Cost per patient Value Worse outcome Higher cost Better outcome Higher cost Worse outcome Lower cost Better outcome Lower cost Outcomes

10 The impact of wounds on health care resources All wounds Non-healing wounds

11 The human cost of wounds Chronic wounds have been shown to have a significant impact on quality of life (QOL) QOL scores suggest that individuals with chronic wounds have a QOL comparable to those with long-term or progressive diseases, such as heart failure Hopman et al. 2009

12 Cost impact of wounds Jorgensen et al Evaluation of a community based educational initiative intended to improve wound care across four districts in Denmark (Aabenraa, Aalborg, Frederiksberg, and Ringsted). Data available from annual wound care audits, baseline + follow-up audits

13 Overview of community based chronic wound care findings (Jorgensen et al) Parameter Result Total number of wounds identified 1103 Proportion chronic wounds 64% Prevalence of patients with a wound Median wound duration Proportion of wounds > 1 year duration Wound duration (days) Mean frequency of dressing change Mean Median Proportion of wounds being dressed on a daily basis Nurse time per wound per week Nurse time allocated to dressing changes/week (hours) /1000 population 280 days 15% (all), 21% (chronic), 5.6% (acute) 280 (all) 353 (chronic) 112 (acute) 91 (chronic) 3.53 per week 23% 61 minutes 1122 hours

Cost impact of wounds Gottrup et al Point prevalence study covering two hospitals and two districts (2010) Captured data on wounds treated in hospital on a given date.

14 Cost impact of wounds Gottrup et al Point prevalence study covering two hospitals and two districts (2010) Captured data on wounds treated in hospital on a given date. Captured data on wounds treated in community over a two week period. Focus on resource consumption Regional Hospital Viborg with a catchment population of around 250,000 Hillerød Hospital with a catchment population of approximately 195,000

15 Overview of community / hospital based chronic wound care findings (Gottrup et al) Parameter Total number of wounds identified Result 306 (hospital) 324 (municipalities) Proportion chronic wounds (hospital) 24% Inpatient prevalence 33% Prevalence of patients with a wound Dressing costs (as a percentage of nurse time + dressings) Mean frequency of dressing change 2.8/1000 municipalities 0.69/1000 hospitals 23-25% (municipalities) 12-29% (hospitals) 21% (all) 4.3 (hospital) 2.8 (municipalities)

16 Aggregated / model data using the Danish surveys

17 Example: Denmark Number of wound patients (caseload) 16,882 Dressing changes per year 3,252,921 Nurse time (hours per year) 987,862 Bed-days per year 339,201 Total cost per year kr. 1,733,991,766

18 Long-duration wounds Nordics area Total population 20.4m Patients with a wound 77,500 Patients with a wound 1 year 10,680 Dressing changes per year (long duration) Bed-days per year (longduration) 2.03m 151,000 Country Denmark Sweden Norway Total cost per year (long duration) kr,. 192m 328m kr kr. 174m Finland 25m

VLUs Highlights the high costs involved in the provision of care for venous leg ulcer patients, particularly for those with hard-to-heal ulcers Hard-to-heal ulcers place a greater demand on resources

19 VLUs Highlights the high costs involved in the provision of care for venous leg ulcer patients, particularly for those with hard-to-heal ulcers Hard-to-heal ulcers place a greater demand on resources compared with other ulcer types. This is not only due to the length of treatment required but also to higher weekly treatment costs. The weekly cost associated with ulcers of long duration was more than twice that associated with ulcers of short duration, irrespective of ulcer size. This was mainly due to increased staff costs as a direct result of more frequent and lengthier dressing changes and a longer time to healing

20 Non-healing wounds: strategies for reducing resource use

21 Reducing dressing change frequency

Releasing health care professionals time One community health provider in the UK undertook an appraisal of ALLEVYN Life in order to understand its usability, acceptability and clinical performance

22 Releasing health care professionals time One community health provider in the UK undertook an appraisal of ALLEVYN Life in order to understand its usability, acceptability and clinical performance (Stephen-Haynes et al 2013) This provider serves a population of over 500,000 people and includes community and practice nurses, community hospitals, long term care facilities and mental health facilities Nurses compared their visit frequency using ALLEVYN Life with what they had been doing before On average, using ALLEVYN Life, they were able to release between one and two visits per week per patient, across the range of wounds included Frequency (times per week) Pre-Life Post-Life Difference All dressings Foams only

Releasing health care professionals time A 2013 evaluation (Stephen-Haynes et al) estimated the potential time released if ALLEVYN Life were to be used for those patients with wounds having 3 or more

23 Releasing health care professionals time A 2013 evaluation (Stephen-Haynes et al) estimated the potential time released if ALLEVYN Life were to be used for those patients with wounds having 3 or more dressing changes per week (estimated at 30% patients or 469 patients) With a reduction in change frequency of 1.64 changes per week, this would release 769 district nursing visits each week This could free up a total of 397 hours of district nursing time per week across the provider Over the course of a year, this strategy could release approximately 40,000 visits (20,644 hours or around 2,500 working days) ,000 20,644 30% patients hours freed up per week visits released per year hours freed up per year

24 Example Parameter All patients Population 500,000 Patient with wounds 1 year Patients 1, Dressing changes per year Reduction in changes per week Dressing changes saved per year 289,000 39,264 1 per patient 1 per patient 78,000 10,749 Nursing hours released 23,525 3,201 Saving in dressing costs 4,290,000 kr 591,169 kr

25 Early intervention to heal non-healing wounds

26 Modelling early intervention for non-healing wounds Portable, single-use NPWT has the potential to deliver good wound outcomes in community care settings

VLUs Prevalence of non-healing VLU in the UK = 20,000 approx (0.3-0.

27 VLUs Prevalence of non-healing VLU in the UK = 20,000 approx ( per 1000 population) Estimated annual cost to treat = 46m Potential cost saving by early intervention and healing of 10% non-healing ulcers = 19,000 over 15 years per 10 ulcers

28 Modelling early intervention for non-healing wounds A proportion of wounds could be classified as long-term nonhealing wounds (e.g. 1 year duration) We assume that these wounds continue to be treated using AWC but remain unhealed However, if we could heal some of these wounds we could: reduce the total wound burden release resources increase service efficiency

29 Continuity of care between hospital and community

Continuity of care Once NPWT is available, continuity of care from acute to community is possible, allowing patients to be discharged on NPWT earlier than would otherwise be the case By treating the

30 Continuity of care Once NPWT is available, continuity of care from acute to community is possible, allowing patients to be discharged on NPWT earlier than would otherwise be the case By treating the patient in the community, there is an estimated cost saving to the NHS of 4814 per patient Targeted use of NPWT, managed by experienced tissue viability staff, is likely to result in more efficient use of resources.

31 Organisational change

32 Niagara Community Care Access Centre Population = 430,000 Patients with a wound = 1,500 Surgical/trauma = 61% Leg/foot ulcer = 25% Pressure ulcer = 14% Prevalence = 3.5 per 1000 >50% of patients receiving care had a wound

33 Niagara CCAC Random sample of 100 patients treated in 2005 & Average weeks to heal Frequency of dressing change Nurse cost per change $51 $51 Materials cost per change $3.75 $28.31 Cost per patient $14,350 3,617 Materials $983 $1,291 Nurse time $13,362 $2,326

34 What was driving change? Healing time more than 50% Stage 3+ pressure ulcers from 39% to 24% VLU compressed from 35% to 90% Daily dressing changes from 49% to 14% The saving in the cost of nurse time: $11,000 per patient

35 Summary 1. Hard to heal wounds require a substantial quantity of resource: mainly hospitalisation and nursing resources 2. Strategies for reducing resource have been proposed: Reducing the frequency of dressing change to release nursing time Reducing the overall number of hard to heal wounds through early intervention Using NPWT to provide continuity of care between hospital and community Using organisational change to increase service efficiency

The true cost of wounds. And how to reduce it

The true cost of wounds. And how to reduce it The true cost of wounds And how to reduce it Wounds are a growing challenge Wounds have been called the silent epidemic. In a typical hospital setting today, between 25% and 40% of beds will be occupied